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The Opioid Crisis Hasn’t Gone Away. It’s Just Gone Underground.

OxyContin maker Purdue Pharma, which played a key role in creating America’s opioid crisis, has dissolved. But the crisis rages on, lives are still in danger, and the profits are still flowing — now to street dealers who manufacture synthetic drugs.

A man holds a piece of foil containing fentanyl. (Jessica Christian / San Francisco Chronicle via Getty Images)

When I inquired about my mom’s prescription drug usage, she went on the defensive.

Writing about the book The Least of Us: True Tales of America and Hope in the Time of Fentanyl and Meth had offered me an opportunity to ask about her current intake, a topic she usually avoids. I was particularly interested to know about her use of opioids.

“Well, I just took an opioid,” she said with bemusement. The term sounded alien spilling from her lips. She usually calls them “headache pills,” rendering harmless the pharmaceuticals that rest permanently on her bedside table. She imagines them as the equivalent of everyday aspirin, rather than addictive substances that have altered her mind and body over time.

At sixty-nine years old, my mom is a shadow of her former self. She suffers from early onset dementia and exists in a foggy mental state, as if permanently stuck waking up from a nap. She’s too drowsy and weak to leave her couch except for about twenty minutes a day to use the bathroom and bathe. She spends most of her time sitting in the dark and watching television. The only time she’s left the house in the last two years was via a stretcher, as EMTs hauled her into the back of an ambulance, to drive her to the hospital to treat her COVID-19 infection.

Opioids have taken away her pain from arthritis, but they’ve also taken away nearly everything else. It’s a Faustian bargain.

Not that she agrees. No argument ever persuades her to stop, and cutting her off has proved an impossible task, especially after my dad died. She was first prescribed opioids for a three-month period. She’s now in her second decade.

“I don’t really think addiction is a big deal if it’s for the right reasons,” she told me. “If it helps me, so what?”

“That sounds exactly like something an addict would say,” I replied. She sighed and fell silent.

A Waking Nightmare

For most of this century, silence reigned as the default American attitude about opioid addiction. When Los Angeles Times journalist Sam Quinones first pitched The Least of Us’s precursor, Dreamland: The True Tale of America’s Opiate Epidemic, to book publishers, he couldn’t find any takers. Addiction to painkillers is hardly a sexy topic, and few understood then just how widespread they’d become.

Quinones’s first book, finally published in 2015, was worth the wait. Dreamland is a riveting account of the United States’ secret addiction that weaves through the complex history of the painkiller industry, both legal and illicit, and documents the major players behind the labs, corporations, and cartels.

Dreamland also narrates harrowing personal stories like my mom’s — stories of ordinary people with chronic pain problems who were overprescribed heroin-like painkillers by their doctors, who themselves were getting pumped and primed by Big Pharma’s army of pill influencers.

The cruel cycle was good business for Purdue Pharma, the makers of OxyContin, and its owners, the plutocratic Sackler family. As their wealth grew exponentially, so did the number of people who got hopelessly addicted or died from an overdose. The Centers for Disease Control and Prevention (CDC) estimated that 500,000 died from opioid overdoses over two decades starting in 1999.

Dreamland and other exposés helped wake Americans up to the fact that opioids were ruining individual lives, families, and whole communities — especially in blue-collar towns and rural areas already ravaged by corporate consolidation, globalization, and capital flight in the neoliberal era.

The term “opioid crisis” was becoming part of the lexicon by the time Donald Trump was elected in 2016. The president declared it a public health emergency a year later, noting that overdoses had joined gun violence and car crashes as a leading cause of death. The sweeping opioid bill he signed in 2018, the SUPPORT for Patients and Communities Act, promised $1.8 billion in state grants to help address the crisis, including provision of more evidence-based treatment for addicts.

State and local governments, hospitals, and individuals targeted Purdue Pharma with thousands of lawsuits over its role in the epidemic. The company pleaded guilty to federal criminal charges for obscuring OxyContin’s addictive properties and for soliciting high-volume prescribers. In September, a bankruptcy court finally dissolved the company and negotiated a settlement worth billions that will compensate 130,000 people who suffered from addiction or whose loved ones died from an overdose.

But it’s all rather cold comfort considering the staggering scale of the crisis that, in addition to the human toll, has cost the country trillions of dollars, including funding for law enforcement, treatment, and social services. The bankruptcy deal also shields the Sacklers from further financial liability. They’re still among the richest families in the United States.

Meanwhile, the Trump administration’s SUPPORT bill strengthened the crackdown on doctors who prescribed opioids and began funding draconian prescription drug monitoring programs. These days doctors, fearing penalties, are beginning to outsource their decision-making to automated programs like NarxCare — a set of databases and algorithms that automatically assigns each patient a unique, comprehensive Overdose Risk Score. (Picture the predictive crime-fighting strategy from the movie Minority Report, but for prescribing legal drugs.) But users are already hooked, and many are turning elsewhere.

A “Street Dealer’s Magic Dust”

The Least of Us is a painful sequel, because it’s an admission that we haven’t beaten the national opioid addiction. Far from it. Quinones makes the convincing case that the problem has simply moved underground, changing locations from the doctor’s office to back alleys, or to the internet, where users purchase drugs from shady Mexican or Chinese chemical providers.

Opioid prescriptions have fallen by at least 60 percent from a decade ago, but demand didn’t suddenly end with the lack of supply. Those seeking similar effects are increasingly turning to the highs of fentanyl and other synthetic drugs. These street drugs are ubiquitous because they deliver a wallop to the body and are cheap to make. Starting a few years ago, traces of fentanyl started showing up in meth, cocaine, and heroin to make those drugs stronger — what Quinones calls a “street dealer’s magic dust.”

The new crop of synthetic street drugs themselves are especially harmful to the human body. Quinones argues that they’re currently ravaging the nation’s brains, leading to a rise in mental illness and a steep uptick in homelessness. Users of synthetic P2P meth, which is produced with a clear liquid called phenyl-2-propanone, are getting hallucinations and delusions, even long-term brain damage. Fentanyl is even more deadly because of its sheer potency. If the manufacturer botches the recipe at all, a small amount can easily kill its users. It’s no wonder that of the 50,000 people who died in opioid overdoses in 2019, nearly 73 percent of the cases involved synthetic drugs.

The death toll has exploded even more since the COVID-19 pandemic began in early 2020. For many, the quarantine and social distancing have exacerbated feelings of anxiety, isolation, and alienation. Over 90,000 people died of a drug overdose last year, according to the CDC, and for the twelve months ending on October 3, 2021, that number was nearly 100,000.

My twenty-two-year-old nephew, who lives with my mom, is both a user and dealer of various synthetic drugs — mostly the former, which is why he’s stolen thousands of dollars from my family over the last few years and racked up a long rap sheet: robbery, assault, counterfeiting, DUIs, possession of illegal firearms, and more. There’s currently a warrant out for his arrest for skipping his trial for a meth possession felony, but the police don’t seem to be in a hurry to take him into custody. The prosecutors tell me that there are too many cases like my nephew’s to handle, and there are bigger fish to fry.

Maybe so, but in the meantime, he quietly partakes of illegal opioids in the back bedroom of my childhood house while my mom ingests the legal kind in the living room.

Who’s to Blame?

It’s natural to want to find someone or something to blame for this new iteration of opioid dependency. But now that the Sacklers are out of the picture, choosing a singular villain is harder.

Accordingly, Quinones struggles to definitively assign blame. Throughout The Least of Us, he takes aim at a variety of targets: our weak pleasure-seeking brains, a consumer society inundated with mass marketing that “primes us for addiction,” and our society’s selfishness. “Our epidemic of opioid addiction was just an extreme expression of a culture in which, in so many ways, Me won the Battle over Us,” he writes.

Least convincingly, he doesn’t find fault with capitalism. Not really. He’s nostalgic for the capitalism of yore, which has “lost its competition” in the post–Cold War period. Now, “Capitalism has bent towards the agglomeration of profit and power in the hands of relatively few,” Quinones writes. In truth, that’s part of capitalism’s origin story — it didn’t change after the Soviet Union fell.

In fact, The Least of Us doubles as an illustration of capitalism’s endurance and ability to pivot and nimbly adapt to perverse new market incentives. Case in point: Once Purdue Pharma was out of the picture, a new, deadlier version took its place in the form of a loose, scattered network of traffickers who are cooking up meth and fentanyl-laced substances on the cheap in Magic Bullet blenders.

“Fentanyl disrupted the traditional drug world just as Amazon and Uber upended retail and taxis and was a boon to traffickers and street dealers. Anybody could be a fentanyl kingpin,” Quinones writes. In other words, the opioid market is now largely the domain of the petty bourgeoisie rather than big corporations. But a few are still profiting while the rest suffer.

The Least of Us is correct when it argues that the United States needs less individualism, more tight-knit communities, a more comprehensive healthcare system, and innovative drug treatment programs. But to get there, we also need to work to create a political and economic system that puts people over profits.

It won’t be easy because capitalism, as it turns out, is one hell of a drug.